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As an expert facilitator of learning, the critical care nurse tailors an educational program on thyroid disease to meet the needs of Rachel and her family. The expert nurse realizes that the patient and family will have various treatment options for hyperthyroidism. The goal of the nurse is to facilitate the patient and family in learning about these options and making the best decision possible. Caring for Rachel will also require the nursing competency of clinical inquiry. The critical care nurse will provide care following practice standards and guidelines for the treatment of thyroid storm, but she will not be afraid to question or deviate from these standards if newer research can help improve patient care. The nurse who is an expert in clinical inquiry will bring evidence based practice to the bedside. Outcome of Case Study Rachel was admitted to the intensive care unit and received aggressive rehydration with dextrose containing I.V. fluids. Due to the patient’s increase in mental confusion, a nasogastric tube was placed to administer PTU every 4 hours. The first dose of iodide in the form of Lugol’s solution was administered one hour after the first dose of PTU and continued every 6 hours. Propranolol was administered every 6 hours for tachycardia and restlessness. Hydrocortisone was given to increase depleted adrenal stores of cortisol. Rachel received acetaminophen every 4 hours for her high fever. In addition, a cooling blanket and ice packs to the axilla and groins were applied. Continuous cardiac monitoring was in place and hemodynamic monitoring was not needed. Rachel stabilized within 24 hours and several days later after thyroid antibody tests returned, she received the diagnosis of Grave’s disease. After educating the patient and family about all available treatment options, a total thyroidectomy was decided upon. The patient underwent surgery without complication and will receive thyroid replacement therapy for life. Rachel and her family were educated on the basics of thyroid disease including signs and symptoms to report. Rachel was referred by the social worker to a family free clinic in the area that can provide free medical follow-up as well as free medications until she finds a job with health insurance. Conclusion Thyroid storm is a rare, life-threatening illness that involves critical and complex care. The Synergy Model can provide a framework to help match complex patient needs and characteristics during thyroid storm with nursing competencies to synergize patient outcomes. Early recognition of the signs thyroid storm and prompt intervention are the key to survival during the eye of the storm. References Andreoli, T., Carpenter, C., Griggs, R., Benjamin, I. (2007). Cecil Essentials of Medicine. Philadelphia, PA: Mosby Elsevier. Belfort, M. A., (2006). Navigating a thyroid storm. Contemporary OB/GYN (October 2006), 38-46. Curley, M. A. (1998). Patient-nurse synergy: optimizing patients’ outcomes. American Journal of Critical Care, 7(1), 64-72. Dahlen, R. (2002). Managing patients with acute thyrotoxicosis. Critical Care Nurse, 22, 62-69. Dulak, S. B. (2005). Thyroid storm: a medical emergency. Modern Medicine. Retrieved November 7, 2009 from http://rn.modernmedicine.com/rnweb/article/articleDetail.jsp?id=153278 Gittoes, N. J. & Franklyn, J. A. (1998). Hyperthyroidism current treatment guidelines. Drugs, 55(4), 543-553. Hardin, S., Hussey, L. (2003). AACN synergy model for patient care case study of CHF patient. Critical Care Nurse, 23(1), 73-76. Kaplow, R., Hardin, S. R. (2007). Critical Care Nursing, Sudbury, MA: Jones and Bartlett Publishers. Kumrow, D. & Dahlen, R. (2002). Thyroidectomy: understanding the potential for complications. Medsurg Nursing, 11(5), 228-235. Young, J. (1999). Actionstat. Thyroid storm. Nursing, (29)8, 33. Table 1 Pertinent Laboratory Findings Lab Test Result High, low, normal White blood cells 3,700/mm3 Normal Hemoglobin 14.2 gm/dL Normal Hematocrit 38.2% Normal Platelets 92,000/uL Low Glucose 82 mg/dL Normal Creatinine kinase (CPK) 3594 IU/L High TSH <0.01 µU/ml Low Free T4 6.22 ng/dl High T3 243 ng/dl High
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